Provider Demographics
NPI:1467921627
Name:MCGOWEN, CARTER KENNY (PA-C)
Entity Type:Individual
Prefix:
First Name:CARTER
Middle Name:KENNY
Last Name:MCGOWEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 E 700 N
Mailing Address - Street 2:
Mailing Address - City:PINE VILLAGE
Mailing Address - State:IN
Mailing Address - Zip Code:47975-8033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:812 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3752
Practice Address - Country:US
Practice Address - Phone:217-443-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-17
Last Update Date:2018-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006617363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant